Inaugural Meeting of the Strategic and Technical Advisory Group on Disease Elimination (Virtual Meeting) Meeting Report and Recommendations
14-15 October 2020
Inaugural Meeting of the Strategic and Technical Advisory Group on Disease Elimination, 14–15 October 2020. Meeting Report and Recommendations
PAHO/CDE/HT/21-0009
© Pan American Health Organization, 2021
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Contents
Introduction ...... 2 1. Objectives ...... 2 2. Methodology and participants...... 2 3. Positioning PAHO’s disease elimination initiative in the evolving context of COVID-19 ...... 3 4. Promotion and operationalization of integrated health service delivery for disease elimination ...... 6 5. Conclusions and Recommendations ...... 7 APENDIX ...... 13 Appendix 1. Members of STAG on Disease Elimination ...... 13 Appendix 2. List of participants ...... 14 Appendix 3. Background Document 1: Setting the Scene – The PAHO Disease Elimination Initiative and the Evolving Context of COVID-19 ...... 16 Appendix 4. Background document 2: Role and Importance of Operational Research in the context of the PAHO Disease Elimination Initiative ...... 22 Appendix 5. Milestones in the Elimination of Communicable Diseases in the Region of the Americas. 24 Appendix 6. Communicable diseases and related conditions candidates for elimination by 2030...... 25 Appendix 7. Agenda ...... 26 Appendix 8. Group photo ...... 28
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Introduction This report provides a summary of the proceedings, conclusions, and recommendations of the first meeting of the PAHO/WHO Strategic and Technical Advisory Group (STAG) on Disease Elimination. Throughout its history, the Pan American Health Organization (PAHO) has played a key role in supporting important disease elimination achievements in the Americas and globally. These achievements were made possible through the adoption of public health approaches that are spelled out in frameworks and sets of recommended disease-control interventions, providing for robust vaccination and mass drug administration programs for targeted neglected infectious diseases as well as, water and sanitation programs and housing quality and safety initiatives. To support the work ahead and reinforce PAHO`s leading role in the disease elimination efforts in the Americas, in October 2019 PAHO Member States endorsed the PAHO Disease Elimination Initiative and a Policy for an Integrated Sustainable Approach to Communicable Diseases in the Americas. The Elimination initiative provides a sustainable framework to orient and guide Member States towards elimination of a group of priority communicable diseases and related conditions. It envisions future generations free of the burden of a set of communicable diseases in the Americas, beginning no later than 2030.
1. Objectives
- Provide advice on strategic interventions to enhance PAHO technical cooperation and accelerate regional response towards disease elimination. - Facilitate discussions regarding evolving issues and priorities for disease elimination in the Region, particularly amidst the evolving context of the COVID-19 pandemic and other potential future disruptions.
2. Methodology and participants
A two-day virtual meeting was held on 14-15 October 2020 with the appointed members of the STAG and delegates of PAHO. A list of the STAG members is given in Appendix 1, while the list of participants is provided in Appendix 2. After introducing participants, presenting the terms of reference of the STAG (available at https://www.paho.org/en/destination-elimination), and appointing the Chair (Patricia Garcia) and Co- Chair (Patrick Lammie), members of the STAG discussed and provided recommendations to PAHO on the following two strategic questions:
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- How can we strategically position the Disease Elimination Initiative (politically, financially, and technically) under and within the evolving context of COVID- 19? - How do we promote and operationalize integrated health service delivery towards disease elimination (especially at the primary healthcare level)? Members of the STAG discussed the available documents of PAHO’s disease elimination initiative (1,2) and two background papers, one for each of the strategic questions, prepared by PAHO’s Secretariat (Appendixes 3 and 4). A debriefing session was held on 15 October by the Chair, Co-Chair, some other members of the STAG, and PAHO delegates with Dr. Carissa Etienne, Director of PAHO, to present the recommendations. A detailed agenda of the meeting is available in Appendix 5 and a group photo in Appendix 6.
3. Positioning PAHO’s disease elimination initiative in the evolving context of COVID-19
After reviewing the background of PAHO’s disease elimination initiative, the steps taken and progress upon its approval by PAHO’s Directing Council in October 2019 (3), and discussing challenges including the evolving context of COVID-19 in the Region of the Americas, the following relevant issues were identified by members of the STAG as priorities for PAHO and countries to position the disease elimination initiative. • PAHO’s disease elimination initiative is relevant to protect the achievements toward disease control and elimination in the Region of the Americas and to accelerate efforts to overcome the challenges imposed by COVID-19 through the framework of health as a human right. Lessons learned from the pandemic, especially those in which community actions contributed to reinforce community-centered approaches, integrated delivery of health services, reinforcement of information systems, among others, should be used to strengthen national and local health capacities towards Universal Health. • PAHO can be catalytic in advocating and creating regional networks of partners, institutions, organizations, including community-based organizations, to reinforce the regional capacities to reach the disease elimination goals. It is important to improve the work on integration and primary health care, aiming at the quality of services and the elimination of diseases. The regional networks should include different levels within country governments, private sector, communities, and media, and should promote and sustain communities of practice. • Reinforcement of local frameworks adapted to local needs and contexts should be promoted by PAHO including key components of resilient health systems such as local empowerment, leadership and
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governance, information systems, health workforce, access to essential medicines, delivery of services, and financing. Documenting investment cases for diseases elimination is an important advocacy tool to show the benefits of the initiative and the role played in strengthening health systems. • Health systems should reinforce the interaction between human, animal and environmental health, through the One Health framework, providing communities with the tools and conditions to monitor, prevent and early response to epidemic of zoonotic and/or vector borne diseases. • PAHO can help countries to identify priorities in the current pandemic context, starting with those diseases showing increased morbidity and mortality due to disruption of health services. The role and leadership of PAHO to reinforce regional and country capacities for people to gain access to essential health services is fundamental as well as to help countries to face the new era for public health after COVID-19 and reach the disease initiative elimination goals. • A monitoring and evaluation framework should be implemented to measure the progress towards the disease elimination goals and targets in countries. Such a tool should identify and measure short and medium-term milestones, with summary indicators, to be reached by countries in the Region as these measures of progress can be an incentive for governments to sustain efforts and make additional investments in the disease elimination initiative as necessary. • Scale up capacities to produce and distribute supplies, materials, diagnostics, vaccines, medicines, and other health commodities, including the reinforcement of the supply chain in the Region of the Americas, is a key aspect on which there are several lessons learned from the pandemic. PAHO’s role is important to reinforce such mechanisms enabling the Region to respond to high demand for supplies and commodities needed to eliminate communicable diseases. • Innovative approaches to increase and sustain access to health services leaving no one behind is fundamental to reach the goals of PAHO disease elimination initiative. Accelerating access to new technologies at local level such as diagnostics (for example, point-of-care test, integrated diagnostic platforms, self-care, and self-testing, among others), telemedicine, medicines, and vaccines, is needed to increase access to health services.
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4. Promotion and operationalization of integrated health service delivery for disease elimination
Members of the STAG discussed the second strategic question on how to operationalize integrated health service delivery, the best approaches to engaging PAHO’s Member States and partners, ways of improving efficient integrated models of care, setting priorities on operational research, and concentrating efforts in populations living in vulnerable conditions, all being priorities for PAHO. The following relevant issues were highlighted: - PAHO and countries should leverage the long history of elimination of communicable diseases in the Region of the Americas as well as the development and investments already made on information health systems, expanded use of rapid diagnostic tests (RDT), point-of-care (POC) tests, integrated surveillance platforms, among others. - Countries should look for opportunities for co-delivery and integration of actions across diseases, platforms, and sectors to accelerate efforts towards the elimination goals. This includes the involvement of communities and community-based organizations as drivers in the decision-making process. The concept of “best values” in public health and actions to tackle the socio-economic, environmental, and cultural factors should be promoted in the Region to eliminate communicable diseases. - PAHO can help countries to tailor their own national disease elimination initiatives and approaches according to their needs and contexts. PAHO can help in the development of country profiles to better understand the context and advocate for tailored approaches, including metrics that summarize the current status on control and elimination of diseases and flag key challenges and progress that are specific to each Country. It is also critical to develop tools to support the operationalization of the disease elimination initiative including tools for prioritization and to estimate costs and perform gap analysis, and check lists that can be applied for each country in preparing its roadmap. Having a few countries as examples of proof-of-concept of the disease elimination initiative could help to advocate for the investment in the elimination initiative across the Region. - The involvement and the voice of communities is an area that needs attention putting in place more inclusive spaces and guarantee of rights for groups that are affected by communicable diseases and diversifying the work of civil society as part of the disease elimination initiative. Capacities should be created and sustained to identify good practices, innovative solutions and opportunities to increase access to integrated inclusive health services for people living in the most vulnerable conditions (key
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populations, migrants, indigenous, afro descendants, prisoners among others) with an intercultural gender-based approach adapted to the local context. - Create and promote integrated options, for example, the elimination of mother-to-child transmission of syphilis, HIV, Hepatitis B and Chagas using the tools provided by PAHO in the EMTCT Plus framework (4) or the integrated packages to eliminate NIDs (5) as they can be very attractive to Ministers and policy makers and draw investments into the disease elimination initiative. • Operational and implementation research capacities should be reinforced and incorporated as a key cross-cutting action in the disease elimination agenda. • In Latin America and the Caribbean most countries have been excluded from external funding mechanisms, but the Region has huge inequalities that need to be addressed. Hence, PAHO should develop strategic fundraising concepts that could offer financial incentives to countries to support the disease elimination initiative. This includes promoting partnerships with financial institutions in the Region, for example with Inter-American Development Bank (IDB), other organizations within the Interamerican system, other agencies of the United Nations System, as well as private foundations among others. • Promote and develop subregional meetings that are critical for countries that share commonalities to identify suitable solutions and opportunities to move towards disease elimination goals. PAHO should provide support to each country based on their contexts, needs, progress, and challenges.
5. Conclusions and Recommendations
Context and preamble: 1. The meeting participants recognized that COVID-19 represents a global tragedy, and that as such, it must be addressed; however, the response to the pandemic must be streamlined so that other public health priorities can continue to receive the attention they deserve. The pandemic has fostered an unprecedented understanding of public health approaches and it has made very clear to the public, the media, government officials, and decision makers the urgency to invest in health to ensure strong and resilient public health systems. 2. The Committee also agreed that Countries of the Americas should not be deprived of the significant public health achievements that were hard won and that this is the right time to move the Communicable Diseases Elimination Initiative forward as it may help protect those health gains as well as the investments made. 3. The STAG recognizes the wealth of experience in integration, innovation, promotion and adoption of new solutions and technologies, and working with vulnerable populations brought by disease control programs into the Elimination Initiative; this public health know how and the many lessons learned in empowering users, synergizing programs and sectors, and strengthening health systems are of
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extreme value in these times of COVID in that they could contribute remarkably to the response to the pandemic and to building resilience in view of future epidemics/pandemics. In this perspective, the STAG deems essential that PAHO play an innovative and catalytic role in all components of the Disease Elimination Initiative, and in appealing to national governments, other sectors of societies including non-governmental institutions, civil society, foundation and funding agencies to engage and support the Initiative.
Priority Strategic Recommendations: 1. STAG welcomes PAHO’s Director supporting the Disease Elimination Initiative as a corporate priority in recognition of its potential role for the achievement of universal health in the Americas. The Committee supports the vision of creating a truly Pan-American movement around the Elimination Initiative, using the example of the Africa CDC during the response to COVID as a model. The STAG further recommends the pursuit of a robust alliance with countries, partners, and donors aiming at protecting the gains achieved in the elimination of diseases, leaving no one behind and accelerating progress toward the 2030 targets. 2. Mindful of the political, economic and social changes that are taking place in the countries of the Region, STAG recommends PAHO to develop a combination of short, medium- and long-term scenarios to guide the DE Initiative towards the 2030 goals. Short-term scenarios would be particularly suitable to facilitate involvement of politicians and local governance, who are often constrained by short time mandates. 3. The meeting highlighted deep concerns about the vulnerability of the Region in ensuring an uninterrupted availability of strategic health commodities during the pandemic, complicated by the dependence of many Member States vis a vis external supply. STAG therefore recommends PAHO to capitalize on the competencies of PAHO’s Revolving and Strategic Funds and continue to assist Member States in strengthening their procurement and supply management systems and at the same time promote and strengthen regional and local technological and production capacity. 4. Recognizing the great potential towards integration built in the framework of the Elimination Initiative, STAG recommends PAHO to duly support those drivers of integration related to health information systems, supply chain management and logistics, and laboratory services, as well as in the engagement and participation of communities and vulnerable populations.
Priority technical recommendations: 1. STAG recommends PAHO to accelerate the adaptation and/or finalization of several tools to facilitate the implementation of the Elimination Initiative, and to prioritize the development of a simple and robust monitoring and evaluation framework for the Elimination Initiative so that the data and knowledge being generated dynamically allow updating the “what to do, where and how to do it”. 2. Amongst those tools, STAG strongly recommends PAHO to create country profiles summarizing the epidemiological data and other strategic information available with regards to those communicable diseases and related conditions that are of particular relevance to each Member State; these tools will facilitate dialogue and planning of operational road maps for disease elimination at national and sub-national levels.
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3. PAHO is recommended to escalate the visibility of the Elimination Initiative through communication, use of social media and engagement of journalists, taking advantage of the window of interest created by the pandemic, and making use of new communication strategies and virtual platforms to reach different audiences and establish communities of practice towards a broad promotion of messages on elimination. 4. STAG recommends PAHO to consider expanding the range of candidates to Elimination by including other diseases/conditions such as HTLV1, in line with the recent WHO pronouncement recognizing HTLV1 as a neglected global public health problem and in recognition of its significant prevalence in the Region.
References
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eng.pdf?sequence=1&isAllowed=y 8. Pan American Health Organization. New Generations Free of HIV, Syphilis, Hepatitis B, and Chagas Disease: EMTCT Plus in the Americas, 2018 [Internet]. Washington, DC; 2019 [cited 2020 Aug 27]. Available from: https://iris.paho.org/bitstream/handle/10665.2/50993/9789275120675_eng.pdf?sequence=2&is Allowed=y 9. Pan American Health Organization. An integrated, Sustainable Framework to Elimination of Communicable Diseases in the Americas. Concept Note [Internet]. 2019 [cited 2020 Aug 22]. p. 68. Available from: https://iris.paho.org/handle/10665.2/51106 10. Pan American Health Organization. A policy for an integrated sustainable approach to communicable diseases in the Americas [Internet]. Washington, DC; 2019 [cited 2020 Aug 24]. Available from: https://www.paho.org/sites/default/files/2020-01/2019-cde-dc57-elimin-init- framework-en.pdf 11. Shretta R, Avanceña AL V, Hatefi A. The economics of malaria control and elimination: a systematic review. Malar J [Internet]. 2016;15(1):593. Available from: https://doi.org/10.1186/s12936-016-1635-5 12. Shwiff SA, Elser JL, Ernst KH, Shwiff SS, Anderson AM. Cost–benefit analysis of controlling rabies: placing economics at the heart of rabies control to focus political will. Rev Sci Tech [Internet]. 2018; Available from: https://doi.org/10.20506/rst.37.2.2833 13. Kunii O, Yassin MA, Wandwalo E. Investing to end epidemics: the role of the Global Fund to control TB by 2030. Trans R Soc Trop Med Hyg [Internet]. 2016 Feb 16;110(3):153–4. Available from: https://doi.org/10.1093/trstmh/trw005 14. Castro KG, Marks SM, Chen MP, Hill AN, Becerra JE, Miramontes R, et al. Estimating tuberculosis cases and their economic costs averted in the United States over the past two decades. Int J Tuberc Lung Dis [Internet]. 2016; Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4992985/ 15. Redekop WK, Lenk EJ, Luyendijk M, Fitzpatrick C, Niessen L, Stolk WA, et al. The Socioeconomic Benefit to Individuals of Achieving the 2020 Targets for Five Preventive Chemotherapy Neglected Tropical Diseases. PLoS Negl Trop Dis [Internet]. 2017 Jan 19;11(1):e0005289. Available from: https://doi.org/10.1371/journal.pntd.0005289 16. de Vlas SJ, Stolk WA, le Rutte EA, Hontelez JAC, Bakker R, Blok DJ, et al. Concerted Efforts to Control or Eliminate Neglected Tropical Diseases: How Much Health Will Be Gained? PLoS Negl Trop Dis [Internet]. 2016 Feb 18;10(2):e0004386. Available from: https://doi.org/10.1371/journal.pntd.0004386 17. Lenk EJ, Redekop WK, Luyendijk M, Fitzpatrick C, Niessen L, Stolk WA, et al. Socioeconomic benefit to individuals of achieving 2020 targets for four neglected tropical diseases controlled/eliminated by innovative and intensified disease management: Human African trypanosomiasis, leprosy, visceral leishmaniasis, Chagas disease. PLoS Negl Trop Dis [Internet]. 2018 Mar 13;12(3):e0006250. Available from: https://doi.org/10.1371/journal.pntd.0006250 18. Pan American Health Organization. COVID-19 Information System for the Region of the Americas [Internet]. [cited 2020 Aug 22]. Available from: https://paho-covid19-response- who.hub.arcgis.com/ 19. Pan American Health Organization. Director’s remarks at Bloomberg Philanthropies’ Webinar “Leading Through Crisis: Reducing the Impact of COVID-19 in Latin America and Africa” - PAHO/WHO | Pan American Health Organization [Internet]. Washington, DC; 2020 [cited 2020 Aug 22]. p. 1–4. Available from: https://www.paho.org/en/documents/directors-remarks-
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bloomberg-philanthropies-webinar-leading-through-crisis-reducing-impact 20. Pan American Health Organization, Economic Commission for Latin America and the Caribbean. Health and the economy: a convergence needed to address COVID-19 and retake the path of sustainable development in Latin America and the Caribbean [Internet]. Washington, DC: PAHO; 2020 Jul [cited 2020 Aug 22]. Available from: https://iris.paho.org/handle/10665.2/52535 21. Pan American Health Organization. Summary of the status of national immunization programs during the COVID-19 pandemic [Internet]. Washington, DC; 2020 [cited 2020 Aug 22]. Available from: https://iris.paho.org/bitstream/handle/10665.2/52544/PAHOFPLIMCOVID- 19200013_eng.pdf?sequence=1&isAllowed=y 22. Pan American Health Organization. 53rd Directing Council 66th Session of the regional Committee of WHO for the Americas. Strategy for Universal Access to Health and Universal Health Coverage [Internet]. Washington, DC; 2014 Oct [cited 2020 Aug 22]. Available from: https://www.paho.org/hq/dmdocuments/2014/CD53-5-e.pdf 23. Pan American Health Organization. The essential public health functions in the Americas: a renewal for the 21st century. Conceptual framework and description (Working document). 2020.
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APENDIX Appendix 1. Members of STAG on Disease Elimination
The STAG is composed of twelve members, who act in their personal capacity and on a voluntary basis, and are appointed by the PAHO Director based on individual qualifications and ability to contribute, ensuring an appropriate balance among fields of knowledge, geographic representation, and gender balance. The following persons will serve for the period 2020-2022: 1. Pedro Cahn (Argentina) – Scientific Director, Fundación Huésped [HIV surveillance and treatment, research institute engagement]. 2. Dirk Engels (Belgium) – Global Health Consultant and Senior Adviser to Uniting to Combat NTDs. Former WHO Director of Dept. of NTD Control [NTD elimination and zoonoses, global program management]. 3. Peter Figueroa (Jamaica) – Professor University of the West Indies [HIV/AIDS epidemiology and university engagement in public health]. 4. Patricia Garcia (Peru) – Former Minister of Health of Peru, Professor and former Dean of the School of Public Health at Cayetano Heredia University [High level health policies, medical informatics and telemedicine, reproductive health]. 5. Claudia Henriquez (Colombia) – Physician, Civil society activist, Secretary of Indigenous Affairs of the department of La Guajira, Colombia [indigenous community engagement in public health actions, health systems and services]. 6. Patrick Lammie (USA) - Chief Scientist for the Neglected Tropical Diseases Support Center, Task Force for Global Health [Translational science, infectious disease elimination, applied immunology]. 7. Nisia Trindade Lima (Brazil) – President, Fundação Oswaldo Cruz (Friocruz), Brazil [Political and high- level advocacy, Universal Health, and primary health care, history of public health policy] 8. Lucia Altagracia Guzman (Dominican Republic) – Former Minister of Health of Dominican Republic, professor of infectious diseases and pediatrics at the Autonomous University of Santo Domingo [high level health policies, public health advocacy and leadership, regulation of infectious diseases and medical practice]. 9. Gina Ogilvie (Canada) – Professor University of British Columbia [Sexual & Reproductive Health, Cervical Cancer and HPV vaccines, community engagement in research]. 10. Regina Rabinovich (USA) – Director, Malaria Elimination Initiative ISGLOBAL, University of Barcelona, and Harvard University [infectious disease elimination and eradication, malaria, donor engagement in disease elimination]. 11. Swarup Sarkar (India) – Former Director, Dept. of Communicable Diseases, SEARO. [Global perspectives and WHO leadership on infectious disease control and elimination]. 12. John Ward (USA) – Program Director, Coalition for Global Hepatitis Elimination, Task Force for Global Health [global public health program management, global elimination of viral hepatitis].
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Appendix 2. List of participants
Pedro Cahn Researcher, Fiocruz Global Health Scientific Director, Fundación Huésped, Buenos Center/FIOCRUZ, Rio de Janeiro, Brazil Aires, Argentina *on behalf of Dirk Engels Nisia Trindade Lima Former WHO Director of Dept. of NTD Control; President, Fundação Oswaldo Cruz (Friocruz), Global Health Consultant and Senior Adviser to Rio de Janeiro, Brazil Uniting to Combat NTDs, Belgium Lucia Altagracia Guzman Peter Figueroa Former Minister of Health of Dominican Professor University of the West Indies, Republic; Professor of infectious diseases and Kingston, Jamaica pediatrics, Autonomous University of Santo Domingo, Dominican Republic. Patricia Garcia Former Minister of Health of Peru Gina Ogilvie Professor and former Dean of the School of Professor, University of British Columbia, Public Health at Cayetano Heredia University, Vancouver, Canada. Lima, Peru Regina Rabinovich Claudia Henriquez Director, Malaria Elimination Initiative Secretary of Indigenous Affairs of the ISGLOBAL, University of Barcelona; Professor, department of La Guajira, Colombia Harvard University, USA.
Patrick Lammie Swarup Sarkar Chief Scientist for the Neglected Tropical Former Director, Dept. of Communicable Diseases Support Center, Task Force for Global Diseases, SEARO. Health, USA John Ward Luiz Augusto Galvao* Program Director, Coalition for Global Hepatitis Elimination, Task Force for Global Health, USA
PAHO Secretariat: Jarbas Barbosa, Assistant Director Steve Ault, Consultant Marcos Espinal, CDE Director Martha Saboya, CDE/VT Massimo Ghidinelli, CDE/HT Unit Chief Leandro Sereno, CDE/HT Luis Gerardo Castellanos, CDE/VT Unit Chief Freddy Perez, CDE/HT Christopher Lim, Chief, Strategic Fund Cristina Mana, CDE Rainier Escalada, CDE/VT Juan David Sanchez, CDE
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Appendix 3. Background Document 1: Setting the Scene – The PAHO Disease Elimination Initiative and the Evolving Context of COVID-19
1. Background and context
Throughout its history, the Pan American Health Organization (PAHO) has played a key role in supporting important disease elimination achievements in the Americas and globally, including leading the eradication of smallpox and elimination of polio and neonatal tetanus from the Americas; and supporting countries in the elimination of endemic transmission of measles, rubella, and congenital rubella syndrome (1,2), as well as the elimination of mother-to-child-transmission of HIV and syphilis in seven countries (Cuba validated by the World Health Organization [WHO] in 2015) (3). Currently, new countries in the Region are approaching the elimination of malaria, in addition to the almost 30 that have already eliminated it since the 70’s (4) and several neglected infectious diseases (5) including leprosy, trachoma (eliminated in one country), lymphatic filariasis (eliminated in three countries), onchocerciasis (eliminated in four countries), and dog-mediated human rabies (eliminated in one country) (Annex 1). Ongoing elimination efforts in the Region have also achieved a substantial reduction in the impact of Chagas disease (6), soil-transmitted helminthiasis (7), schistosomiasis, and fascioliasis in children and other populations at risk. Likewise, the elimination of mother-to-child transmission of hepatitis B and Chagas disease is also within reach, backed up by an integrated conceptual framework for quadruple elimination known as EMTCT Plus (8), pushed into implementation through an innovative validation strategy which has informed the finalization of a global WHO standard process.
These and other1 achievements were possible through the adoption of public health and sound environmental approaches that are spelled out in frameworks and sets of interventions, providing for robust vaccination and mass drug administration programs for targeted neglected infectious diseases as well as, water and sanitation programs and housing quality and safety initiatives.
To support the work ahead and reinforce PAHO`s leading role in the disease elimination efforts in the Americas, in October 2019 Member States have endorsed the PAHO Disease Elimination Initiative (9) and A Policy for an Integrated Sustainable Approach to Communicable Diseases in the Americas (10). This initiative provides a sustainable framework to orient and guide the work of the Member States and the technical cooperation of the Organization towards the elimination as a public health problem of a group of priority communicable diseases and related conditions. It envisions future generations free of the burden of a set of communicable diseases in the Americas, beginning no later than 2030.
Building on a background of pioneering, innovative, and successful interventions, and relying on and promoting cross-cutting principles of gender, equity, human rights, and ethnicity, the Elimination Initiative articulates four lines of action: 1) Strengthening the Integration of Health Systems and Service Delivery, 2) Strengthening Strategic Health Surveillance and Information Systems, 3) Addressing the Environmental and Social Determinants of Health, and 4) Strengthening Governance, Stewardship, and Finance.
1 Elimination Initiative: "Building a Better Future for Younger Generations" - Overview (PDF Format) https://www.paho.org/en/documents/elimination-initiative-building-better-future-younger-generations-overview-pdf-format
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The lines of action are mutually complementary and highlight the leading role of local health authorities in partnership with civil society to ensure the provision of a comprehensive set of interventions that simultaneously address the four dimensions of elimination, namely: prevent new infections, stop (or reduce) mortality, stop (or reduce) morbidity, and prevent or minimize disability.
The economic benefits expected from the elimination of those conditions are significant. The value of the investment in the elimination of communicable diseases at the global level is well-recognized. Systematic reviews have demonstrated that the per capita investments needed for elimination compare to costs identified for the control of diseases (malaria (11) and rabies (12)); it is also estimated that elimination may generate important economic returns, including great benefits for health systems, communities and societies at large (13–17). Limited information and data are available for the Region of the Americas, and the expected return on investment of integrated interventions, benefit-cost ratios, and cost savings of elimination are elements that will be addressed throughout the implementation of the initiative, including comparison with the projected costs of inaction (status quo, or control without elimination). Also, several specific disease control and elimination funded initiatives are already being carried out across the Region. Besides substantial domestic resources invested by countries, there is complementary funding provided by partner agencies such as the Global Fund, the President's Emergency Plan for AIDS Relief (PEPFAR), United States Agency for International Development (USAID), United States President’s Malaria Initiative (PMI), Global Affairs Canada, The Carter Center, END Fund, UN Foundation, Inter- American Development Bank (IADB), Spanish Agency for International Development (AECI), among others. Diseases that historically lack adequate investment can be incorporated into existing frameworks and take advantage of well-funded strategies through optimal use of funds. However, the financial scenario would need to be reevaluated given the current COVID-19 pandemic and its impact on national health systems, planning, and resource allocation.
The number and scope of communicable diseases and related conditions in the Americas is large and wide (Annex 2). Therefore, the focus of the Elimination Initiative will be on a key group of diseases (9,10) that represent a significant burden, disproportionally affect the more vulnerable populations in the Region, and whose elimination is feasible using available and innovative technical means. These are HIV, including mother-to-child-transmission; syphilis, including congenital syphilis; hepatitis B; hepatitis C; yellow fever; Chagas disease, including congenital Chagas; as well as malaria, leishmaniasis, schistosomiasis, soil- transmitted helminthiasis, onchocerciasis, lymphatic filariasis, fascioliasis, trachoma, leprosy, yaws, tuberculosis, cholera, plague, and human rabies.
The initiative also addresses the risk of reintroduction of vaccine-preventable diseases such as rubella, including congenital rubella syndrome, measles, and poliomyelitis, and the control of outbreak-prone diseases such as cholera, plague, and yellow fever through the International Health Regulations. In addition to these communicable diseases, cervical cancer has been recognized as a disease with great potential for elimination as a public health problem, as well as certain environmental determinants related to communicable diseases, including the elimination of open defecation and of polluting biomass cooking fuels, both of which are linked to widespread public health problems in specific geographic areas.
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2. Steps taken and progress
The development of the Elimination Initiative has represented a multidisciplinary activity within the PAHO secretariat, and it has involved the Member States and key partners as well. A core-team coordinates the process within the Department of Communicable Diseases and Environmental Determinants of Health; an Interdepartmental Working Group ensures a corporate approach towards implementation, advocacy, and monitoring of the initiative, and contribution from a wide range of Department and Units within PAHO. Also, PAHO’s Director has established an external Strategic and Technical Advisory Group with the task of providing high-level advice to the Organization on strategies, policies, and actions in support of a regional agenda for disease elimination.
A communication campaign for the dissemination of the Elimination Initiative has been initiated including the development of a series of audio and visual materials2. The Destination Elimination web portal was launched in 2019 as a repository of documentation and tools related to the Elimination Initiative and its target diseases, including technical guidance, epidemiological profiles, reports of successful experiences, and best practices from the Region.
Also, an advocacy campaign has been initiated in which PAHO personnel have presented the Elimination Initiative conceptual framework and called on allies for support within and beyond the health sector across the Region. So far, several partners have signaled interest in supporting the Elimination Initiative, and PAHO has engaged in official partnerships to carry out joint activities on disease elimination in the Americas.
The key partners on this endeavor, PAHO Member States, have committed to the Elimination Initiative through the endorsement of the PAHO Resolution CD57.7, during the 57th PAHO Directing Council in October 2019. Preliminary discussions were initiated with individual countries to undertake pilot activities under the Elimination Initiative Framework. For instance, Uruguay and Costa Rica were preparing national integrated missions to address the elimination of several diseases that are relevant to their settings (now on hold due to the pandemic), while Ecuador has developed a National Plan for Diseases of Potential Elimination. Due to the COVID-19 pandemic such missions are to be postponed for later dates.
3. The way forward, challenges and opportunities
Despite the Region’s success histories, experiences, and a comparative advantage in disease elimination, much remains to be done. The current elimination agenda needs to be accelerated to protect and maintain gains and continue advancing the response to communicable diseases. Before the onset of the COVID-19 pandemic, the ongoing demographic and epidemiologic transition, the deep health inequities prevailing in the Region, the rising burden of non-communicable diseases, and widening resource constraints were already identified as main challenges affecting public health responses at the country and regional level, bringing a negative outlook for the elimination agenda (9). At present, the disruption caused by COVID-19 exacerbates some of these issues while imposing very high morbidity and mortality rates (18), and disproportionately affecting the poor, those with underlying health conditions, as well as population groups of higher vulnerability (19,20). The pandemic crisis is increasing the vulnerability of
2 Video on the Elimination Initiative “know how it works” available at https://www.youtube.com/watch?v=aFM7ZeIuNAQ
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women, indigenous and Afro-descendant populations, migrants and refugees, and pose other groups such as the elders and people with disabilities at a higher risk of infection across Latin America and the Caribbean (20).
The path to achieving the milestones proposed in the Elimination Initiative is now under threat due to the burden of COVID-19 on the provision of essential health services, including programs people depend on to manage conditions, and priority diseases control programs, elimination initiatives, and routine immunization. Challenges in delivering TB treatments during the pandemic were reported by 80% of the countries in Latin America and the Caribbean (LAC). Similarly, 30% of people living with HIV report avoiding seeking care, while stocks and incoming supplies of antiretroviral medications are severely constrained. Disruptions in hepatitis screenings, key for detection and treatment, were also reported by a third of the countries. Mass drug administration has been postponed in all neglected infectious diseases endemic countries, including deworming for children 1-14 years of age. Report of malaria cases has gone down more than 40% with an observed large reduction in the number of people getting tested. The number of doses of vaccines distributed for diphtheria, tetanus, and pertussis (DPT) and measles, mumps, and rubella (MMR) have decreased between 12% and 14% in 23 countries (21), and more than a quarter of countries have suspended or paused routine vaccination campaigns. Disruptions in the delivery of medical supplies, vaccines, medicines, primarily consequent to closure of borders and international air and sea connections, have been reported. This complicates further ongoing discontinuation of primary health care services, epidemiological surveillance, and laboratory services due to a combined effect of the shift in priorities towards SARS-CoV-2 cases and the population’s fear of infection (20).
Health systems in LAC countries show significant weaknesses, including barriers to access that are the result of years of inadequate public investment. Over the past decades, public spending in health, while slowly increasing in the Americas, has been persistently low, and in many cases, insufficient, averaging 3.7%, far below PAHO’s recommended 6.0% of gross domestic product (GDP) (22). In 2020, it is expected a reduction in growth in the order of 9.1% in LAC due to the pandemic, equivalent to a loss of 10 years of hard-earned gains in the Region (20).
PAHO and the Economic Commission for Latin America and the Caribbean (ECLAC) have highlighted that rebuilding more inclusive and resilient societies after the pandemic means viewing health as a human right and a public good that must be guaranteed by the State, with sufficient funding. Universal access to health should be expanded and stronger, resilient health systems strengthened based on a primary health care approach, prioritizing the most vulnerable populations. The policy options for addressing the pandemic entails consolidating a national plan and intersectoral consensus (20). PAHO’s renewed agenda on essential public health functions facilitates an understanding of current public health challenges, highlighting the social determinants of health, equity, and an integrated approach to individual and collective public health services (23). The pandemic has revealed weaknesses in the health systems to respond and be resilient to threats, but it has also open opportunities for a more broad and comprehensive approach to tackling the root causes of the communicable diseases and conditions addressed by the PAHO’s Elimination Initiative. Now it is most urgent to defend the relevance of the initiative, to identify ways and means of consolidation and adjustment to fit the new context and take advantage of the foreseeable shifts that countries will implement to recover from the COVID-19 pandemic. The Elimination Initiative should continue to be seen as key to catch up and accelerate the progress towards the SDGs.
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4. Questions to the STAG
Question 1: How can we strategically position the Disease Elimination Initiative (politically, financially, and technically.) under and within the evolving context of COVID-19? • Is the infrastructure deployed so far and the corresponding measures established adequate for sustaining a long term, complex, multidisciplinary, and horizontal undertaking? Ways and means for consolidation. • How do we protect the relevance of the Elimination Initiative? What are the adjustments needed to readapt the initiative to the new context? The Initiative would require some adjustments, help identify priority updates and corrections. • How can elimination of communicable diseases and the Elimination Initiative remain an attractive case for investment and be recognized as a key source of interventions to catch up and accelerate the progress towards SDGs?
Question 2: How do we promote and operationalize integrated health service delivery towards disease elimination (especially at the primary healthcare level)? • What would be the best approaches to engage Member States and partners in the Elimination Initiative and how to operationalize interprogrammatic efforts towards the elimination of diseases? • The provision of integrated and people-centered service has been a great challenge in the countries of Latin America and the Caribbean. How can PAHO promote integrated models of care more efficiently through the Elimination Initiative? • Knowledge gaps still exist, and operational research presents itself with a prominent role in addressing these gaps. What should be the focus of operational research and how to guarantee efficient use of research results? • How to highlight the most vulnerable populations and other groups and guarantee that they are not left behind on the way towards the elimination of diseases? • What should we prioritize within PAHO, in our interaction with the Member States and with others (organizations, partners, stakeholders, etc.)?
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Appendix 4. Background document 2: Role and Importance of Operational Research in the context of the PAHO Disease Elimination Initiative
Operations Research features high in the agenda for the implementation of PAHO’s Disease Elimination Initiative. It is key to define effective local strategies as well as to promote sustainable implementation of disease specific interventions. It is defined in terms of “knowledge on interventions, strategies, or tools that can enhance the quality, effectiveness, or coverage of programs”.3 Operational research may provide insights on how to promote the uptake and successful execution of evidence-based interventions considering both the demand and supply sides with emphasis in communities that most need them.
It is through this approach that the effectiveness of the interventions is evaluated under real-life conditions, and that their acceptability and the best methods of delivery are determined with the aim of improving health systems and health care delivery. Operational research can help address questions about effectiveness of interventions being promoted by the Disease Elimination Initiative to benefit specific population groups or indicate ways to enhance effectiveness of current strategies or evaluate novel approaches.4
OR builds upon the availability of a wide range of routinely collected data used to assess program performance while facilitating integration into service delivery models as well as promoting program management. Additionally, an interdisciplinary approach and intersectoral collaborations should be contemplated in order to address the numerous research requirements of the Disease Elimination Initiative
In this perspective, there is a need to strengthen the capacity for operational research in the Latin American and Caribbean Region together with supporting national research policies. This will enable strengthening actions regarding situation analysis and research priority setting as well as investing in training opportunities and building local research capacities, undertaking resource mobilization and monitoring the overall implementation of research activities. Furthermore, it is imperative that research findings become easily accessible, widely disseminated so that they could reach decision makers and program managers and ensure the use of evidence for policy.
A set of research priorities are to be defined within the Elimination Initiative Framework in close coordination with the national health research policy of the countries of the Region and engaging a wide range of stakeholders (public health practitioners, civil society, academic and research institutions, PAHO collaborating centers, among others). These priorities should be selected with regards to the expected public health benefits, in consideration of cost and feasibility of their implementation and looking at possible partnerships at with the service-delivery or the program-implementation level in order to fully reflect local needs.
Here three examples that highlight the relevance of operational research in the Region: 1) The use of mass drug treatment (preventive chemotherapy) with a combination of drugs for lymphatic filariasis,
3 Zachariah R, Harries AD, Ishikawa N, et al. Operational research in low-income countries: what, why, and how? Lancet Infect Dis. 2009; 9:711–717 4 Peters DH, Adam T, Alonge O, Agyepong IA, Tran N. Implementation research: what it is and how to do it. BMJ. 2013;347
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onchocerciasis, schistosomiasis, intestinal helminthiases and trachoma where knowledge gaps still exist on how to continue implementing this strategy in the most acceptable, cost-effective and sustainable way5-6; 2) the implementation of the framework for the elimination of mother-to-child transmission (EMTCT-Plus) in a disperse rural population from the Gran Chaco region that requires adequate implementation strategies to overcome health system diversities7; and 3) recent data suggests that schistosomiasis transmission has been interrupted on Saint Lucia. Additional surveys of adults, snails, and a repeat survey among school-age children will be necessary to verify these findings8.
A call for submission of operational research proposals was issued early 2020 but was put on hold due to the COVID-19 pandemic. This initiative is expected to resume once the situation has improved. The intention is to mobilize resources required to generate action and support, facilitate and strengthen elimination-oriented operational research. We seek guidance from the STAG on; 1) supporting the principle of promoting OR, and 2) expanding areas and topics for the development of research questions and protocols.
To achieve disease elimination in the America, there is a need of effective implementation of proven interventions to improve health outcomes. However, knowledge gaps concerning the ‘’what, why, and how’ interventions work in the ‘real world’ setting exists. Operational research integrates research and practice to accelerate the development and delivery of public health approaches. It is necessary to prioritize operational research interventions in the PAHO Disease Elimination Initiative and guarantee the efficient use of research results into policy and practice.
5 Webster JP, Molyneux DH, Hotez PJ, Fenwick A. The contribution of mass drug administration to global health: past, present and future. Philos Trans R Soc Lond B Biol Sci 2014; 369: 20130434 6 Bitran R, Martorell B, Escobar L, Munoz R,Glassman A. Controlling and eliminating neglected diseases in Latin America and the Caribbean. Health Aff (Millwood) Nov-Dec 2009;28(6):1707-19. 7 Crudo F, Piorno P, Krupitzki H et al. How to implement the framework for the elimination of mother-to-child transmission of HIV, syphilis, hepatitis B and Chagas (EMTCT Plus) in a disperse rural population from the Gran Chaco region: A tailor-made program focused on pregnant women. PLoS Negl Trop Dis. 2020 May 28;14(5):e0008078. 8 Gaspard J, Usey MM, Fredericks-James M, Sanchez-Martin MJ et al. Survey of Schistosomiasis in Saint Lucia: Evidence for Interruption of Transmission. Am J Trop Med Hyg. 2020 Apr;102(4):827-831.
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Appendix 5. Milestones in the Elimination of Communicable Diseases in the Region of the Americas
Source: PAHO. Destination: Elimination. Ending Communicable Diseases in the Americas. Washington, DC. PAHO 2020. https://www.paho.org/en/documents/brochure-destination-elimination-ending- communicable-diseases-americas
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Appendix 6. Communicable diseases and related conditions candidates for elimination by 2030
*There are different target dates between now and 2030 used by PAHO/WHO for each candidate disease or condition, however in general terms we are using the SDG target date of 2030.
Source: PAHO. Elimination Initiative: "Building a Better Future for Younger Generations" – Overview (Presentation). Washington, DC. PAHO: 2020. https://www.paho.org/en/documents/elimination- initiative-building-better-future-younger-generations-overview-pdf-format
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Appendix 7. Agenda
Inaugural Meeting of the Strategic and Technical Advisory Group on Disease Elimination October 14 and 15, 2020 (Virtual Meeting)
General Objective:
Provide feedback to PAHO senior management on strategic interventions to enhance PAHO technical cooperation and accelerate regional response towards disease elimination.
Specific Objectives: • Inaugurate the members of the Strategic and Technical Advisory Group on Disease Elimination (STAG-DE) and present its operational management and functions. • Facilitate discussions among members regarding evolving issues and priorities on disease elimination in the Region, particularly amidst the evolving context of the COVID-19 pandemic and other potential future disruptions.
Day 1 – October 14 (Wednesday), 09:00 am to 12:30 pm (EST)
Time Agenda Item Participants 09:00 – 10:15 Session 1: Welcome remarks and Procedures Moderation: Dr. Massimo Ghidinelli 05 min Rules of Procedure and ZOOM platform Cristina Mana
20 min Welcome Message: Dr. Jarbas Barbosa Dr. Jarbas Barbosa, Assistant Director, PAHO
20 min Brief Self-introduction of STAG-DE Members, Secretariat, All Observers
15 min Presentation of STAG-DE Terms of Reference Dr. Massimo Ghidinelli
10 min Appointment of Chair and Co-Chair of the STAG-DE
05 min Agenda 10:15 – 10:30 Break
10:30 – 11:30 Session 2: Setting the Scene Moderation: Chair/Co-Chair 15 min The PAHO Disease Elimination Initiative and the Evolving Dr. Marcos Espinal Context of COVID-19:
45 min Moderated discussion STAG Members 11:30 – 12:30 Session 3: Strategic Questions to the STAG Moderation:
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Time Agenda Item Participants Chair/Co-Chair Introduction Strategic Question #1 – How can we strategically position the STAG Members to the Disease Elimination Initiative (politically, financially, and question + technically) under and within the evolving context of COVID- Discussion 19?
12:30 pm Adjournment of Day 1 Chair/Co-Chair
Day 2 – October 15 (Thursday), 09:00 am to 12:30 pm (EST)
Time Agenda Item Participants 09:00 – 09:15 Summary of Day 1 Dr. Luis Gerardo Castellanos 09:15 – 10:15 Session 3: Strategic Questions to the STAG (cont.) Moderation: Chair/Co-Chair introduction Strategic Question #2 – How do we promote and STAG Members of the operationalize integrated health service delivery towards question + disease elimination (especially at the primary healthcare Discussion level)? 10:15 – 10:30 Break 10:30 – 12:00 Internal / Closed Discussion of STAG-DE: Consolidation of STAG Members (Actionable) Draft Recommendations for PAHO 12:00 – 12:30 Report back to the group 12:30 pm Closure Chair/Co-Chair Dr. Marcos Espinal
Debriefing session with PAHO Director (October 15th, 2020)
Time Agenda Item Participants 15th Oct Debriefing session with Dr. Carissa Etienne, Director of the Pan STAG Chair/Co-Chair 03:30 – 04:15 pm American Health Organization STAG Members Chair and Co-Chair to present the STAG recommendations to Secretariat the Pan American Health Organization.
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Appendix 8. Group photo
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Inaugural Meeting of the Strategic and Technical Advisory Group on Disease Elimination (Virtual Meeting)
Meeting Report and Recommendations
14-15 October 2020